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Observation and discussion with the Director of Facilities, the Maintenance Lead, and the Corporate Compliance Officer between 8:30 am and 3 pm on 9/14/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Corridor walls shall form a barrier to limit the transfer of smoke [Re: NFPA 101, Life Safety Code, 2000: ? 19.3.6.2.2.]

Findings: The corridor walls [rated wall separation] were observed above the dropped ceiling and wall penetrations were observed that were not sealed properly. The facility staff sealed these openings immediately, but other areas within the hospital probably need attention as well. The facility shall affirm that all penetrations have been caulked properly.

Observation and discussion with the Director of Facilities, the Maintenance Lead, and the Corporate Compliance Officer between 8:30 am and 3 pm on 9/14/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

a. Fire Alarm Control Panel

Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and service shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit [Re: NFPA 72, National Fire Alarm Code, 1999: ? 1-5.2.5.2.]

Findings: The FACP, located on the 3rd floor, did not meet this requirement. The facility shall ensure that this requirement is met with the main FACP and all booster panels as well.

Observation and discussion with the Director of Facilities, the Maintenance Lead, and the Corporate Compliance Officer between 8:30 am and 3 pm on 9/14/2011 revealed that certain requirements stipulated in NFPA 13 were not met.

a. Spare Sprinkler Heads

A supply of spare sprinklers [never fewer than six] shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced [Re: NFPA 13, Installation of Sprinkler Systems, 1999: ? 3-2.9.1.]

Findings: The staff indicated that spare sprinkler heads were not maintained on the premises.

Observation and discussion with the Director of Facilities, the Maintenance Lead, and the Corporate Compliance Officer between 8:30 am and 3 pm on 9/14/2011 revealed that certain requirements stipulated in NFPA 90A and the State Licensing Rules were not met.

a. Filter Certification

Air filters shall be rated either as Class 1 or Class 2 in accordance with UL 900, Standard for Safety Air Filter Units [Re: NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999: ?2-2.2.2.]

Findings: The Class of the sheet filters utilized for the units installed in the mechanical rooms was not apparent.

b. Level of Filtration

All central air handling systems serving patient care areas, including nursing unit corridors, shall be equipped with filters having efficiencies equal to, or greater than, those specified for those types of areas in Table 4 of ?134.131(d) of this title. .... [Re: 25 TAC, PPH&CSU LR, 2004: 134.122(d)(3)(E)(ii).]

Findings: The level of filtration, according to the staff, was MERV 8 [30%], as opposed to the required level of 90% for patient care areas. The facility shall ensure that the required levels of filtration are met.

c. Multiple Filters

The units referenced in " b " above, are required to have multiple filter banks in order to achieve the quality of air specified for patients in Table 4 of ?134.131(d) of this title. .... [Re: 25 TAC, PPH&CSU LR, 2004: 134.122(d)(3)(E)(ii).]

Findings: None of the units surveyed were equipped with multiple filter banks. The facility shall ensure that the required filtration parameters are satisfied.

d. Air Intakes

The bottom of outside air intakes serving central units serving central systems shall be located as high as practical but at least six feet above ground level, or if installed above the roof, three feet above the roof level [Re: 25 TAC, PPH&CSU LR, 2004: 134.122(d)(3)(E)(i)(IV).]

Findings: The dysfunctional RTU did not meet this requirement. If the decision is made by the facility to repair and return this unit to service, the 36 " rule must be observed.

e. System Changes

No new system of mechanical, electrical, plumbing, fire protection, or piped medical gas system may be installed or any such existing system be replaced, materially altered or extended in an existing building licensed as a facility, until complete plans and specifications for the replacement, installation, alteration, or extension have been submitted to the department, reviewed and approved in accordance with ?134.127 of this title [relating to Preparation, Submittal, Review and Approval of Plans] [Re: 25 TAC, PPH&CSU LR, 2004: 134.121(a)(2)(B).]

Findings: Observation of the single RTU revealed that it was dysfunctional, in the process of alteration since tools were scattered around the unit, and the staff indicated that the prognosis was undetermined. This rule was not followed.

f. Pressure Relationships

All rooms and areas in the facility listed in Table 3 of ?134.131[c] of this title shall have provision for positive ventilation. ..... [Re: 25 TAC, PPH&CSU LR, 2004: 134.122(d)(3)(E)(i).] The referenced table requires patient toilet rooms to be negatively pressurized, 10 changes per hour, and all exhaust to be exhausted from the building.

Findings: Observation indicated that the toilet room for Patient Room 205 was not negatively pressurized as required. The facility shall ensure that all toilet rooms, janitor closets and soiled utility rooms are negatively pressurized.

Observation and discussion with the Director of Facilities, the Maintenance Lead, and the Corporate Compliance Officer between 8:30 am and 3 pm on 9/14/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with 10.3.1 [Re: NFPA 101, Life Safety Code. 2000: ? 19.7.5.1.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Director of Facilities, the Maintenance Lead, and the Corporate Compliance Officer between 8:30 am and 3 pm on 9/14/2011 revealed that certain requirements stipulated in NFPA 99 and the State Licensing Rules were not met.

a. Preferred Customer Status

The Department requires Letters of Preference for critical resources to be retained by the Facility for two items: fuel and water [Re: NFPA 99, Health Care Facilities,1999: ?11-5.3.2.]

Findings: The letters for fuel and water were not available for review.

b. Use of PVC

Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waster-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC, HLR, 2007: ? 133.162(d)(4)(A)(viii)(I).]

Findings: During the survey, PVC installations were observed in the Dietary Suite and in the 2nd floor mechanical room. These should be replaced with nonflammable materials.

c. Nurse Call System

A nurses regular calling system shall be provided for the treatment [exam] room(s) in accordance with ?134.122(d)(5)(K)(i) of this title [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(e)(5)(B).] A nurses regular calling system is intended for routine communication between each patient and the nursing staff. Activation of the system at a patient ' s regular calling station will sound a repeating [every 20 seconds] audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The audible signal shall be canceled and two-way voice communication between the patient room and the nursing staff shall be established at the unit ' s nursing station when the call is answered by the nursing staff. The visible signal[s] in the corridor shall be canceled upon termination of the call. An alarm shall activate at the nurses station when the call cable is unplugged [Re: 25 TAC, PPH&CSU LR, 2004: 134.122(d)(5)(K)(i).]

Findings: The requirement for a nurse call functionality between the nurses station the treatment or exam room[s] is enforced by the Department. A nurse call system was installed at one time, but it is now dysfunctional. The nurse call system must be listed by an agency such as UL and it must be UL1069 compliant.

d. Window Sills

Each patient sleeping room shall have an outside window. The windows shall be restricted. Where the operation of windows requires the use of tools or keys, the tools or keys shall be located at each nurses station, on the same floor, and easily accessible to staff. The window sill shall not exceed 36 inches above the floor [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(3)(A)(iv).]

Findings: The patient rooms on the 2nd floor had the windows covered with an opaque covering up to about 6 feet, thereby denying the patient any daylight or view of the outdoors. This is not code compliant.

Observation and discussion with the Director of Facilities, the Maintenance Lead, and the Corporate Compliance Officer between 8:30 am and 3 pm on 9/14/2011 revealed that certain requirements stipulated in NFPA 70 and NFPA 99 were not met.

a. Circuit Breakers

The circuit breakers that are impacted by transfer switch operation shall be exercised annually pursuant to manufacturer ' s recommendations [Re: NFPA 99, Health Care Facilities, 2002: ? 3-4.4.1.2.]

Findings: The staff indicated that these tests were not conducted and records were not available for review.

b. GenSet Light & Receptacle

No function other than those listed in (a) through (f) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment: ... ...(e) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location [Re: NFPA 70, National Electrical Code, 1999: ?517-32(e).]

Findings: These amenities were not installed as required.

Observation and discussion with the Director of Facilities, the Maintenance Lead, and the Corporate Compliance Officer between 8:30 am and 3 pm on 9/14/2011 revealed that certain requirements stipulated in NFPA 70 and the State Licensing Rules were not met.

a. Functional Allocation

Specific requirements exist identifying the functions as they must be allocated to the critical branch [NFPA 70, National Electrical Code, 2002, ?517.33], life safety branch [NFPA 70, National Electrical Code, 2002, ?517.32], and the equipment system [NFPA 70, National Electrical Code, 2002, ?517.34].

Findings: During the survey, a number of functions were determined to be improperly circuited. The facility shall ensure that only the proper loads are circuited from the appropriate panelboards.

b. Component Labels

All boxes and enclosures (including transfer switches, transformers, distribution panels, and panelboards) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system [Re: NFPA 70, NEC, 2002: 700.9(A).]

Findings: The above listed components shall be labeled with the words " CRITICAL BRANCH " , " LIFE SAFETY BRANCH " or " EQUIPMENT BRANCH " to be readily identifiable as part of the Essential Electrical System.

c. Circuit Directory

All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard [Re: NFPA 70, National Electrical Code, 2002: ? 408.4.]

Findings: All circuit directories must be updated to be legible and meaningful.

d. Exam or Treatment Room Receptacles

Each treatment [or exam] room shall have a minimum of six duplex electrical receptacles. Two duplex electrical receptacles shall be located convenient to the head of the bed [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(e)(5)(A)(i).]

Findings: The three exam rooms had 4, 3, and 3 receptacles for the 1st, 2nd and 3rd floors, respectively.

e. Exam or Treatment Room Work Counters

Each work counter and table shall have access to two duplex receptacles connected to the critical branch of the emergency electrical system and be labeled with panel and circuit number [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(e)(5)(a)(ii).]

Findings: The three exam rooms had 0, 1, and 0 critical-powered receptacles for the 1st, 2nd and 3rd floors, respectively. The facility shall ensure this requirement is satisfied.

f. Patient Suite Power

I. Each patient bed location shall be supplied by at least two branch circuits, one from the critical branch of the emergency system as required by NFPA 99, ?3-4 and one from the normal system. All branch circuits from the normal system shall originate in the same panelboard [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(6)(A)(ii).]

II. One duplex receptacle connected to a normal branch circuit and one duplex outlet connected to the critical branch circuit shall be located on opposite sides of the head of each bed. In addition, at least one duplex outlet shall be located on each wall. A dedicated outlet shall be provided at the television location [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(6)(A)(iii).]

III. One duplex receptacle shall be installed in the bathroom to permit the use of electrical appliances in front of the mirror [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(6)(A)(vi).]

IV. Receptacles shall be protected by GFCI breakers installed in distribution panel enclosures serving the nursing suite [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(6)(A)(vii).]

Findings: None of the requirements cited above were met by the facility. The facility shall ensure these requirements are satisfied.

g. Patient Suite Lighting

I. Each patient room shall be provided with general lighting and night lighting. General lighting and night lighting shall be controlled at the room entrance. All controls for lighting in patient areas shall be of the quiet operating type. Control of night lighting circuits may be achieved by automatic means and in such instances control of night lighting at the room entrance shall not be required. At least one general light fixture and night lighting shall be powered from the critical branch of the essential electrical system [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(6)(C)(iii)(I).]

II. A reading light shall be provided for each patient. Reading light control shall be readily accessible from each patient bed. High heat producing light sources such as incandescent and halogen shall be avoided to prevent burns to patients and/or bed linen. Light sources shall be covered by a diffuser or a lens [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(6)(C)(iii)(II).]

III. A wall or ceiling mounted lighting fixture shall be provided above each lavatory [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(6)(C)(iii)(III).]

IV. A ceiling mounted fixture shall be provided in patient bathrooms where the lighting fixture above the lavatory does not provide adequate illumination of the entire bathroom. Some form of fixed illumination shall be powered from the critical branch [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(6)(C)(iii)(IV).]

Findings: None of the requirements cited above were met by the facility. The facility shall ensure these requirement are satisfied.

Observation and discussion with the Director of Facilities, the Maintenance Lead, and the Corporate Compliance Officer between 8:30 am and 3 pm on 9/14/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Corridor walls shall form a barrier to limit the transfer of smoke [Re: NFPA 101, Life Safety Code, 2000: ? 19.3.6.2.2.]

Findings: The corridor walls [rated wall separation] were observed above the dropped ceiling and wall penetrations were observed that were not sealed properly. The facility staff sealed these openings immediately, but other areas within the hospital probably need attention as well. The facility shall affirm that all penetrations have been caulked properly.

Observation and discussion with the Director of Facilities, the Maintenance Lead, and the Corporate Compliance Officer between 8:30 am and 3 pm on 9/14/2011 revealed that certain requirements stipulated in NFPA 72 were not met.

a. Fire Alarm Control Panel

Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and service shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit [Re: NFPA 72, National Fire Alarm Code, 1999: ? 1-5.2.5.2.]

Findings: The FACP, located on the 3rd floor, did not meet this requirement. The facility shall ensure that this requirement is met with the main FACP and all booster panels as well.

Observation and discussion with the Director of Facilities, the Maintenance Lead, and the Corporate Compliance Officer between 8:30 am and 3 pm on 9/14/2011 revealed that certain requirements stipulated in NFPA 13 were not met.

a. Spare Sprinkler Heads

A supply of spare sprinklers [never fewer than six] shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced [Re: NFPA 13, Installation of Sprinkler Systems, 1999: ? 3-2.9.1.]

Findings: The staff indicated that spare sprinkler heads were not maintained on the premises.

Observation and discussion with the Director of Facilities, the Maintenance Lead, and the Corporate Compliance Officer between 8:30 am and 3 pm on 9/14/2011 revealed that certain requirements stipulated in NFPA 90A and the State Licensing Rules were not met.

a. Filter Certification

Air filters shall be rated either as Class 1 or Class 2 in accordance with UL 900, Standard for Safety Air Filter Units [Re: NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999: ?2-2.2.2.]

Findings: The Class of the sheet filters utilized for the units installed in the mechanical rooms was not apparent.

b. Level of Filtration

All central air handling systems serving patient care areas, including nursing unit corridors, shall be equipped with filters having efficiencies equal to, or greater than, those specified for those types of areas in Table 4 of ?134.131(d) of this title. .... [Re: 25 TAC, PPH&CSU LR, 2004: 134.122(d)(3)(E)(ii).]

Findings: The level of filtration, according to the staff, was MERV 8 [30%], as opposed to the required level of 90% for patient care areas. The facility shall ensure that the required levels of filtration are met.

c. Multiple Filters

The units referenced in " b " above, are required to have multiple filter banks in order to achieve the quality of air specified for patients in Table 4 of ?134.131(d) of this title. .... [Re: 25 TAC, PPH&CSU LR, 2004: 134.122(d)(3)(E)(ii).]

Findings: None of the units surveyed were equipped with multiple filter banks. The facility shall ensure that the required filtration parameters are satisfied.

d. Air Intakes

The bottom of outside air intakes serving central units serving central systems shall be located as high as practical but at least six feet above ground level, or if installed above the roof, three feet above the roof level [Re: 25 TAC, PPH&CSU LR, 2004: 134.122(d)(3)(E)(i)(IV).]

Findings: The dysfunctional RTU did not meet this requirement. If the decision is made by the facility to repair and return this unit to service, the 36 " rule must be observed.

e. System Changes

No new system of mechanical, electrical, plumbing, fire protection, or piped medical gas system may be installed or any such existing system be replaced, materially altered or extended in an existing building licensed as a facility, until complete plans and specifications for the replacement, installation, alteration, or extension have been submitted to the department, reviewed and approved in accordance with ?134.127 of this title [relating to Preparation, Submittal, Review and Approval of Plans] [Re: 25 TAC, PPH&CSU LR, 2004: 134.121(a)(2)(B).]

Findings: Observation of the single RTU revealed that it was dysfunctional, in the process of alteration since tools were scattered around the unit, and the staff indicated that the prognosis was undetermined. This rule was not followed.

f. Pressure Relationships

All rooms and areas in the facility listed in Table 3 of ?134.131[c] of this title shall have provision for positive ventilation. ..... [Re: 25 TAC, PPH&CSU LR, 2004: 134.122(d)(3)(E)(i).] The referenced table requires patient toilet rooms to be negatively pressurized, 10 changes per hour, and all exhaust to be exhausted from the building.

Findings: Observation indicated that the toilet room for Patient Room 205 was not negatively pressurized as required. The facility shall ensure that all toilet rooms, janitor closets and soiled utility rooms are negatively pressurized.

Observation and discussion with the Director of Facilities, the Maintenance Lead, and the Corporate Compliance Officer between 8:30 am and 3 pm on 9/14/2011 revealed that certain requirements stipulated in NFPA 101 were not met.

Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with 10.3.1 [Re: NFPA 101, Life Safety Code. 2000: ? 19.7.5.1.]

Findings: This requirement was discussed and it was determined that the required documentation is not retained by the staff.

Observation and discussion with the Director of Facilities, the Maintenance Lead, and the Corporate Compliance Officer between 8:30 am and 3 pm on 9/14/2011 revealed that certain requirements stipulated in NFPA 99 and the State Licensing Rules were not met.

a. Preferred Customer Status

The Department requires Letters of Preference for critical resources to be retained by the Facility for two items: fuel and water [Re: NFPA 99, Health Care Facilities,1999: ?11-5.3.2.]

Findings: The letters for fuel and water were not available for review.

b. Use of PVC

Soil stacks, drains, vents, waste lines, and leaders installed above ground within buildings shall be drain-waster-vent (DWV) weight or heavier and shall be: copper pipe, copper tube, cast iron pipe, or galvanized iron pipe [Re: 25 TAC, HLR, 2007: ? 133.162(d)(4)(A)(viii)(I).]

Findings: During the survey, PVC installations were observed in the Dietary Suite and in the 2nd floor mechanical room. These should be replaced with nonflammable materials.

c. Nurse Call System

A nurses regular calling system shall be provided for the treatment [exam] room(s) in accordance with ?134.122(d)(5)(K)(i) of this title [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(e)(5)(B).] A nurses regular calling system is intended for routine communication between each patient and the nursing staff. Activation of the system at a patient ' s regular calling station will sound a repeating [every 20 seconds] audible signal at the nurse station, indicate type and location of call on the system monitor, and activate a distinct visible signal in the corridor at the patient suites door. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. The audible signal shall be canceled and two-way voice communication between the patient room and the nursing staff shall be established at the unit ' s nursing station when the call is answered by the nursing staff. The visible signal[s] in the corridor shall be canceled upon termination of the call. An alarm shall activate at the nurses station when the call cable is unplugged [Re: 25 TAC, PPH&CSU LR, 2004: 134.122(d)(5)(K)(i).]

Findings: The requirement for a nurse call functionality between the nurses station the treatment or exam room[s] is enforced by the Department. A nurse call system was installed at one time, but it is now dysfunctional. The nurse call system must be listed by an agency such as UL and it must be UL1069 compliant.

d. Window Sills

Each patient sleeping room shall have an outside window. The windows shall be restricted. Where the operation of windows requires the use of tools or keys, the tools or keys shall be located at each nurses station, on the same floor, and easily accessible to staff. The window sill shall not exceed 36 inches above the floor [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(3)(A)(iv).]

Findings: The patient rooms on the 2nd floor had the windows covered with an opaque covering up to about 6 feet, thereby denying the patient any daylight or view of the outdoors. This is not code compliant.

Observation and discussion with the Director of Facilities, the Maintenance Lead, and the Corporate Compliance Officer between 8:30 am and 3 pm on 9/14/2011 revealed that certain requirements stipulated in NFPA 70 and NFPA 99 were not met.

a. Circuit Breakers

The circuit breakers that are impacted by transfer switch operation shall be exercised annually pursuant to manufacturer ' s recommendations [Re: NFPA 99, Health Care Facilities, 2002: ? 3-4.4.1.2.]

Findings: The staff indicated that these tests were not conducted and records were not available for review.

b. GenSet Light & Receptacle

No function other than those listed in (a) through (f) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment: ... ...(e) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location [Re: NFPA 70, National Electrical Code, 1999: ?517-32(e).]

Findings: These amenities were not installed as required.

Observation and discussion with the Director of Facilities, the Maintenance Lead, and the Corporate Compliance Officer between 8:30 am and 3 pm on 9/14/2011 revealed that certain requirements stipulated in NFPA 70 and the State Licensing Rules were not met.

a. Functional Allocation

Specific requirements exist identifying the functions as they must be allocated to the critical branch [NFPA 70, National Electrical Code, 2002, ?517.33], life safety branch [NFPA 70, National Electrical Code, 2002, ?517.32], and the equipment system [NFPA 70, National Electrical Code, 2002, ?517.34].

Findings: During the survey, a number of functions were determined to be improperly circuited. The facility shall ensure that only the proper loads are circuited from the appropriate panelboards.

b. Component Labels

All boxes and enclosures (including transfer switches, transformers, distribution panels, and panelboards) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system [Re: NFPA 70, NEC, 2002: 700.9(A).]

Findings: The above listed components shall be labeled with the words " CRITICAL BRANCH " , " LIFE SAFETY BRANCH " or " EQUIPMENT BRANCH " to be readily identifiable as part of the Essential Electrical System.

c. Circuit Directory

All circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel door in the case of a panelboard, and at each switch on a switchboard [Re: NFPA 70, National Electrical Code, 2002: ? 408.4.]

Findings: All circuit directories must be updated to be legible and meaningful.

d. Exam or Treatment Room Receptacles

Each treatment [or exam] room shall have a minimum of six duplex electrical receptacles. Two duplex electrical receptacles shall be located convenient to the head of the bed [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(e)(5)(A)(i).]

Findings: The three exam rooms had 4, 3, and 3 receptacles for the 1st, 2nd and 3rd floors, respectively.

e. Exam or Treatment Room Work Counters

Each work counter and table shall have access to two duplex receptacles connected to the critical branch of the emergency electrical system and be labeled with panel and circuit number [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(e)(5)(a)(ii).]

Findings: The three exam rooms had 0, 1, and 0 critical-powered receptacles for the 1st, 2nd and 3rd floors, respectively. The facility shall ensure this requirement is satisfied.

f. Patient Suite Power

I. Each patient bed location shall be supplied by at least two branch circuits, one from the critical branch of the emergency system as required by NFPA 99, ?3-4 and one from the normal system. All branch circuits from the normal system shall originate in the same panelboard [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(6)(A)(ii).]

II. One duplex receptacle connected to a normal branch circuit and one duplex outlet connected to the critical branch circuit shall be located on opposite sides of the head of each bed. In addition, at least one duplex outlet shall be located on each wall. A dedicated outlet shall be provided at the television location [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(6)(A)(iii).]

III. One duplex receptacle shall be installed in the bathroom to permit the use of electrical appliances in front of the mirror [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(6)(A)(vi).]

IV. Receptacles shall be protected by GFCI breakers installed in distribution panel enclosures serving the nursing suite [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(6)(A)(vii).]

Findings: None of the requirements cited above were met by the facility. The facility shall ensure these requirements are satisfied.

g. Patient Suite Lighting

I. Each patient room shall be provided with general lighting and night lighting. General lighting and night lighting shall be controlled at the room entrance. All controls for lighting in patient areas shall be of the quiet operating type. Control of night lighting circuits may be achieved by automatic means and in such instances control of night lighting at the room entrance shall not be required. At least one general light fixture and night lighting shall be powered from the critical branch of the essential electrical system [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(6)(C)(iii)(I).]

II. A reading light shall be provided for each patient. Reading light control shall be readily accessible from each patient bed. High heat producing light sources such as incandescent and halogen shall be avoided to prevent burns to patients and/or bed linen. Light sources shall be covered by a diffuser or a lens [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(6)(C)(iii)(II).]

III. A wall or ceiling mounted lighting fixture shall be provided above each lavatory [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(6)(C)(iii)(III).]

IV. A ceiling mounted fixture shall be provided in patient bathrooms where the lighting fixture above the lavatory does not provide adequate illumination of the entire bathroom. Some form of fixed illumination shall be powered from the critical branch [Re: 25 TAC, PPH&CSU LR, 2004: 134.123(n)(6)(C)(iii)(IV).]

Findings: None of the requirements cited above were met by the facility. The facility shall ensure these requirement are satisfied.